Week 6 (Class 2) - Musculoskeletal & Mobility Assessment Flashcards
What are factors that affect MSK health?
There are a whole lot of factors to consider when we’re looking at MSK health:
- Lifestyle
- Exercise/activity, fitness, BMI
- Diet, calcium, supplementation
- Alcohol/smoking (heavy alcohol consumption in youth/young adult increases risk for OP later on)
- Sun exposure, vitamin D (need vitamin D to absorb Calcium)
- Occupational influences, risk/repetitive strain, trauma, mechanism of injury
- Gender influences
Woman are prone to greater bone loss because of estrogen losses after menopause
- General health
What is fragility fracture? Who are they most commonly found in?
This type of fracture occurs from a standing height or less
- The body should be capable of falling in such a way without fracture, so indicates fragility of the bone (as opposed to traumatic fall/injury resulting in a fracture
These type of fractures are most commonly found in the hip, wrist, and spine.
- Represent 80% of all fractures in menopausal women over age 50
What if recent fracture AND steroid use present?
High risk for fracture regardless of bone density
What subjective data do you collect for MSK?
Assessment of risk factors:
- Demographic data
- Past medical history steroids,
- Family history = scoliosis, congenital abnormalities of hip or foot, arthritis: RA, OA, gout, ankylosing spondylitis (this one is inflammatory, over time some of the bones of the spine can fuse together which deteriorates flexibility and posture, and can cause breathing difficulties if the ribs are involved), DDD, genetic disorders: osteogenesis imperfecta (OI) for example (video in a few slides from here)
- Nutrition and medications = steroids, cancer meds (chemo=loss of muscle mass/muscle weakness), quinolones in children (these are a family of antibiotics, contraindicated in kids related to concerns of toxic build up in cartilage)
- Psychosocial history = How much help, if any, does the person have?
Do they work, volunteer, care for others (elderly patients caring for elderly spouses is common)
Level of competence? Safety? Support?
What are they able to do? What are they no longer able to do? How does this affect them socially, emotionally?
Where are the gaps? What’s missing? ie. support, services, income, care
How participatory are they in the things that they enjoy
- Occupation, lifestyle, and behaviours
- Functional assessment =
FUNCTIONAL ASSESSMENT IS KEY WITH THIS SYSTEM-it is its own focus, also woven throughout
Others:
General = fever, weight loss/gain, fatigue/weakness, rashes, injuries, etc.
Joints = including those not involved in the overall complaint; history of arthritis/osteoarthritis/rheumatoid arthritis, stiffness, decreased ROM, swelling, redness, pain, unilateral vs. bilateral
Muscles = limitations of movement, weakness, paralysis, shortening, tremor, wasting, pain
Skeletal = limp or difficulty with gait, posture, pain with/without movement, crepitus, change in skeletal contour (like neck/spine ie. scoliosis), past injuries/conditions ie. degenerative disc disease (DDD)
Infections - of the joints and/or muscles
What is unique to paediatrics with MSK?
Because of ++ blood flow to the ends of long bones and areas of rapid growth, so bacteria can easily get there and cause joint infections.
- Very young kids have immature immune systems making it even easier to establish infection, and infections can impair their growth leading to long term disability
- Symptoms can be masked by injury (kids are constantly injuring themselves) leading to delayed identification and treatment
What does past medical history include? Why would you include past medial history in subjective data?
Which includes current diagnoses, particularly trauma, previous joint/bone surgery, chronic illness, cancer, arthritis, osteoporosis, renal (uremic myopathy, damage/weakness/wasting of muscles, chronic kidney disease, build up of metabolic waste in the blood, damages muscles and nerves causing cramping/spasm/pain) or neurological disorder (damaged nerves which don’t communicate well with muscles for motor function), congenital abnormalities or skeletal deformities
Why might cancer be something to think about in terms of skeletal integrity?
- When cancers metastasize to bones this can lead to pathological fractures, which cause deep bone pain and can be caused by as little as rolling over in bed.
Why is subjective data important in MSK?
The patient may not realize that his kidney disease has anything to do with his MSK health, so you should be the one to decide where to probe in the history. Remember that it’s not up to the patient to determine relevancy, it’ up to us.
- Try not to ask the patient for ‘relevant’ information, because they might omit something that they didn’t realize you wanted to know.
- Just be strategic with your questioning.
What are special circumstances to MSK?
- Fracture due to cancer
- Pregnancy
- Scoliosis
- Polio
What happens to the MSK during pregnancy?
- Increased levels of circulating hormones may increase mobility of joints (Relaxin)
- Changes in maternal posture – lordosis
- Compensate for enlarging fetus – centre of gravity shifts
- Strain or lower back muscles and pain in late pregnancy
- Sciatic nerve pain from pressure
- Anterior flexion of neck, slumping of shoulders to compensate
Joints get ‘loose’ in prep for birth
- Compression of nerves, sciatic for example, in later pregnancy
- Posture changes like lordosis produce pain
- Bone health – calcium – fetus requires it, so it needs to be available
- If not enough calcium ingested from diet and supplements, the body will break down mother’s bones to meet fetal requirements
What are lifespan considerations when assessing MSK?
Newborns, infants, and children
a) Legs
- Bowlegged (genu varus) until ~ 18 mos
- Transition to knock-knee (genu valgus)
- Legs usually straighten by 6 - 7 years
b) Fontanels
- anterior closed by 18 - 24 months
- posterior closed by 2 months
c) Back
- Check for scoliosis (especially ages 10-16)
d) Other:
- 3 months gestation – fetal skeleton is formed (cartilage)
- Cartilage ossifies into real bone and starts to grow.
- Epiphysis (growth plate) at each end of bone
- Closure of epiphysis occurs at ~ 20 years.
- Spine curvature at birth C shape
- 3-4 months raising the head establishes the cervical curve
- 9 – 18 months standing develops anterior curve
Older adults
- Much of what we do to promote health in older adults revolves around safety, general maintenance of bone and muscle, and falls prevention
- The increase in morbidity and mortality that happens after an older adults falls/falls and fractures is sharp
- Maintaining function is important to keep older adults in their own homes and as independent as possible
Cultural considerations
How can one prevent falls?
- Exercise to strengthen leg muscles
- Remove or tape down loose rugs (We all need to say no to the scatter mat)
- Eliminate floor clutter
- Footwear with good treads
- Leave lights/night-light on
- Railings and grab bars
- Raised toilet seats
- Install indoor or outdoor lighting
- Let the answering machine get that ringing telephone.
- Step on your cat’s tail, it will learn its lesson
- Have the giant dog go down the stairs before you
- RNAO BPG Fall Prevention 2011
What should you consider when gathering objective data for MSK?
When we are assessing our client’s posture, look way down to the foundation and observe their stance
- Posture may be erect, slouching, asymmetrical
1) Static and dynamic
2) Gait and mobility
3) Balance
4) Coordination
5)
what is static vs dynamic posture?
Static posture
- This is how a person presents themselves in stance
- It is the base from which the individual moves
- A weak foundation can lead to more problems
Dynamic posture
- This is how an individual holds themselves while performing functional tasks. - How does the static posture influence the way the individual walks, runs, reaches, bends etc.
What is gait and mobility?
- Joint specific mobility
- Total body mobility
- Stance to locomotion
- Naturally and effectively move through ROM
- Apply this to total body function
1) Gait
- walking pattern; should be smooth & coordinated, feet lift off the ground, stride is long, heel-toe manner, arms swing in opposition, eyes off the ground
2) Mobility
- think from the smallest ailment to the total body- think of it as a rate limiting cause- if a single joint is inadequate it will lead to other detriments potentially causing a bigger issue (think back to posture)
Gait/Patterns of movement - smooth; shuffling (Parkinsonian); antalgic (painful gait); Ataxic gait – generally uncoordinated, lacks order in the movement
What is balance? What is the romberg test?
- Cerebellum
- Integration of somatosensory, vestibular, and visual stimuli
To maintain center of gravity without swaying – think back to posture and gait – where is the center of gravity/ base of support and what kinds of functionality does the patient want?
Romberg test – is normally for neurological assessment but can be useful here
+ve Romberg means there is increasing loss of balance
Romberg looks for the origins or cause of ataxia
Romberg may be applied in this context for that reason—what can we rule out
